CurrentAnthemPolicy 61088Camenabc

ACA Preventive Care Drug List

List of preventive drugs and products covered at 100% cost-share under the Affordable Care Act for Anthem/Carelon plans, with age or population-specific limitations and some quantity limits and prior form requirements for certain categories.

Policy Summary

PayerAnthem

PolicyACA Preventive Care Drug List

Policy CodePolicy 61088Camenabc

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must provide a prescription for OTC preventive products to obtain 0% cost-share coverage for members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes to policy (has_material_change = false).

12Major preventive categories listed

2Bowel prep kits allowed per year

6Age-based coverage thresholds

Coverage Summary

This document is the ACA Preventive Care Drug List for Anthem/Carelon plans. It lists preventive drugs and products that must be covered at 100% (no member cost-share) under the Affordable Care Act. The list includes specific drugs and products by name, and states age, quantity, and form requirements (for example, age limits for fluoride and statin eligibility, and a two‑kit per year limit for bowel prep). It also explains that prescriptions are required for OTC items and that certain coverage or $0 cost-share may require completion of provider forms (for example, copay waiver forms for breast cancer prevention or brand contraceptives).

Surface thresholds

Bowel prep kits per year2 kits per year

Statin eligibility age range40-75 years

Fluoride age range6 months to 16 years

Folic acid age limitWomen 55 years or younger

Metformin (prediabetes) age range35-70 years

Smoking cessation age limitGreater than 18 years

Medical‑Necessity / Coverage Criteria

Aspirin

Covered for specific prevention use:

Aspirin for preeclampsia prevention

Product and use: Generic over-the-counter 81 mg aspirin products to prevent preeclampsia in pregnant women
Formulations covered: aspirin 81mg (tab, ec tab, chew)

Bowel Prep

Coverage conditions and limits:

Bowel prep coverage and limits

Generic prescription and OTC covered: Generic prescription and over-the-counter bowel prep products are covered
Annual quantity limit: Limit: two (2) bowel prep kits per year2 kits per year
Applies to adults 45-75 years
Age requirement: Age: adults 45 - 75 years old45-75 years
Examples of covered bowel prep agents
- bisacodyl
- bisacodyl-PEG 3350 combos: bisacodyl-peg 3350-pot chloride-sod bicarb sod chloride magnesium citrate, hydroxide
- Nulytely (generic): peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic Nulytely)
- Moviprep (generic): peg 3350-kcl-nacl-na sulfate-na ascorbate- ascorbic acid (generic Moviprep)
- Suprep (generic): polyethylene glycol 3350 na sulfate-k sulfate-mg sulf (generic Suprep)

Breast Cancer prevention agents

Coverage at $0 requires completed form; prior breast cancer diagnosis alters cost-sharing:

Breast cancer prevention agent coverage

Copay waiver required: Doctor must complete the Breast Cancer Copay Waiver form for $0 coverage for prevention
Prior diagnosis cost-share: If previous diagnosis of breast cancer exists, applicable cost share will apply (not $0)
Examples of covered preventive agents
- anastrozole 1mg
- exemestane 25mg

Cardiovascular (statins)

Full coverage for low-to-moderate dose generics with eligibility limits:

Statin preventive coverage criteria

Age requirement: Member age between 40 and 75 years old40-75 years
Cardiovascular risk factors: Member has one or more cardiovascular risk factors (dyslipidemia, diabetes, hypertension, or smoking)
No prior CVD event: Member has not experienced a cardiovascular disease event
Covered statins examples

Fluoride

Coverage limited by age and generic-only:

Fluoride (children) coverage

Generic-only sodium fluoride products covered
Age requirement: Coverage for children age 6 months to 16 years6 months to 16 years
Example formulations
- sodium fluoride chew formulations: sodium fluoride chew 0.25mg, 0.5mg, 1mg, 2.2mg
- sodium fluoride tablet:

Folic Acid

Generic-only coverage for reproductive-aged women:

Folic acid coverage

Generic-only: Generic folic acid products (prescription and OTC) covered
Age/population: Coverage for women ages 55 or younger who are planning and able to get pregnant<=55 years
Formulations examples
- folic acid 400mcg & 800mcg: folic acid tab,cap 400mcg, 800mcg

HIV Pre-Exposure Prophylaxis (PrEP)

Coverage applies for PrEP use; treatment use may have cost share:

PrEP coverage criteria

Indication: Coverage applies when drug is used for pre-exposure prophylaxis (PrEP)
Treatment vs PrEP: If used for HIV treatment, cost share may apply based on benefit
Covered PrEP agents listed
- Apretude
- Descovy 200-25mg

Prediabetes

Full coverage condition:

Prediabetes metformin coverage: Full coverage of metformin 850mg is limited to members 35-70 years old who have prediabetes35-70 years

Smoking Cessation

Coverage criteria:

Smoking cessation coverage

Age requirement: Member age: greater than 18 years old>18 years
Included therapies
- OTC Nicotine Replacement: OTC (Brand and Generic) Nicotine Replacement Gum, Lozenge and Patch
- bupropion SR 150mg
- Nicotrol Inhaler and Nasal Spray: Nicotrol Inhaler; Nicotrol Nasal Spray

Vaccines

Preventive vaccines listed (implied ACA coverage):

Preventive vaccines list: BCG; COVID-19; Diphtheria, Tetanus, Pertussis; Haemophilus B Polysac Conj; Hepatitis A; Hepatitis B; Human Papillomavirus (HPV); Influenza Virus; Measles, Mumps & Rubella Virus; Meningococcal; Mpox; Pneumococcal; Poliovirus, IPV; Rotavirus, Oral; Respiratory Syncytial Virus (RSV); Varicella Virus; Zoster (shingles)

Covered Preventive Medications and Products (by name)

Listed covered preventive medications and products (by name)mixedCovered

aspirin 81mg	OTC generic aspirin 81 mg formulations (tab, ec tab, chew) for preeclampsia prevention in pregnancy
bisacodyl	Bowel prep agent (generic)
polyethylene glycol 3350 (PEG 3350) / Suprep / Moviprep / Nulytely / Golytely	Bowel prep kits (generic equivalents)
anastrozole 1mg	Breast cancer prevention agent
exemestane 25mg	Breast cancer prevention agent
letrozole 2.5mg	Breast cancer prevention agent
raloxifene 60mg	Breast cancer prevention agent
tamoxifen 10mg, 20mg (Soltamox)	Breast cancer prevention agent
atorvastatin 10-20mg	Low-to-moderate dose generic statin (cardiovascular prevention)
fluvastatin 20-80mg	Statin

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Provider Actions & Billing Rules

Documentation Required

Prescription required for OTC preventive drugs

Providers must provide a prescription for OTC preventive products to obtain 0% cost-share coverage for members.

Prior Authorization

Breast Cancer Copay Waiver form for $0 coverage

Provider must complete and submit the Breast Cancer Copay Waiver form to secure $0 coverage for breast cancer prevention agents; if prior breast cancer exists, cost share applies.

Prior Authorization

Brand Contraceptive Copay Waiver form

Providers can complete and return the Brand Contraceptive Copay Waiver form when preferred contraceptives are inappropriate to request waiver of cost share for non-formulary brand contraceptives.

Billing Rule

Bowel prep quantity limit

Plan limits coverage to two (2) bowel prep kits per member per year for adults 45-75; providers/pharmacies should not exceed this when billing.

2 kits per year for adults 45-75
Do not exceed this limit when billing

Background

Under the ACA, pharmacy benefits must cover certain preventive drugs and products at 100% (no copay, deductible, or coinsurance). This policy document lists the specific items covered by Anthem/Carelon, and includes the applicable age limits, quantity limits, and procedural requirements. It notes that providers must write a prescription for OTC preventive products for them to be covered at no cost, and that specific waiver forms (for example, the Breast Cancer Copay Waiver form or the Brand Contraceptive Copay Waiver form) must be completed to secure $0 cost-share in certain situations. The document also specifies category rules and limits such as two (2) bowel prep kits per year for adults 45–75, fluoride coverage for children 6 months to 16 years, folic acid for women ≤55 planning pregnancy, metformin for prediabetes in members 35–70, and statin eligibility for members 40–75 with one or more cardiovascular risk factors and no prior CVD event.

Policy Summary

PayerAnthem

PolicyACA Preventive Care Drug List

Policy CodePolicy 61088Camenabc

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must provide a prescription for OTC preventive products to obtain 0% cost-share coverage for members.

SourceLink

On This Page

Golytely (generic): peg 3350-kcl-sod bicarb-sod chloridesod sulfate (generic Golytely)

tamoxifen (Soltamox) 10mg, 20mg: Soltamox tamoxifen 10mg, 20mg

atorvastatin 10-20 mg: atorvastatin (10 - 20 mg)

fluvastatin 20-80 mg: fluvastatin (20 - 80 mg)

lovastatin 10-40 mg: lovastatin (10 - 40mg)

pravastatin 10-80 mg: pravastatin (10 - 80mg)

rosuvastatin 5-10 mg: rosuvastatin (5 - 10mg)

simvastatin 5-40 mg: simvastatin (5 - 40mg)

sodium fluoride tab 0.5mg, 1mg

sodium fluoride solution: sodium fluoride soln 0.25mg, 0.5mg, 0.125mg

pediatric multivitamin with fluoride: pediatric multivitamin/ fluoride chew, tab, soln 0.25mg, 0.5mg, 1mg,0.125mg, 1.1mg, 2.2mg

Prenatal and multivitamins with folic acid (generic OTC only)

emtricitabine-tenofovir 200-300mg

Yeztugo tab: Yeztugo 300mg tab

Yeztugo injection: Yeztugo Inj

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